general & specialized ortho practices

Your only concern at this point should be to obtain an Orthopaedic residency position. You should do Ortho because you love it and couldn't imagine doing anything else. Your future career prospects will fall into place as time goes on. If you don't want to do 90% of hips/knees, you don't have to! No one is forcing you to do that. Become a shoulder surgeon or spine or whatever you please. The orthopods that are doing 90% hips/knees love doing hips and knees and they also realize that the demand there is ENORMOUS, with the baby boomers aging and what have you. And as far as that taking care of your patients and "doctoring", if you wanted to do more of that, and less cutting, then go become a social worker, or go into "touchy feely" medicine like Hem/Onc.

That seems a tad illogical ... how are you supposed to know that you love ortho and want a position without asking these questions. How your life/career will look will obviously be important in making this decision. I'm trying to figure out what different kinds of practices are available, and what kinds of procedures you end up doing. I want to know that I can sustain a practice doing the things I love in ortho.

Basically, I'm trying to determine what the major subsets are. There are joint guys who do only elective hips and knees, so it's obviously a highly lucrative direction with a great lifestyle, although maybe a little lacking in variety? On the other end are the trauma guys, with great variety and exciting cases, but lifestyle is nearly as bad as the general surgeons with frequent calls. Sports, as far as I can tell, is also a great lifestyle, but involves fewer open cases and more injections/scopes.

Are those subsets accurate? Any more info would be helpful ... because my point is that I like mixing all those things together, but can't imagine being happy doing only one subset in the future.

Thanks,
b

First,
You are correct. General surgeons do more "medical management" of their patients. I am not sure the "fine surgical skills" of general surgeons is true as I have (and I am sure you have) seen a lot of hacks. Ortho is an awesome feild that you can do so many different things:
Sports
TJA
Spine
Hand
Foot and Ankle
Trauma
Peds

The reason we do not medically manage our patients is b/c we are smart enough to realize that their are people who can do that better than us. They are called internists. We spend 5-7 years doing a surgical residency/fellowship. Of course we are going to lose some medical management skills. Do we care how the lungs sound.....YES. Are their people that can manage diabetes better...yes.

If you want more medical management go into medicine or G-surg. It is not that orthopods can not learn how to manage patients medically, it is that we no our limits and respect internists.

Thanks for the great response ... makes a lot of sense.

I understand why we should defer to internists, but I assume we still maintain some base of medical knowledge, is that true? How much of that do you get in an ortho residency? I mean there's a whole 1st year of gen surg, so I assume that's pretty broad training. Do you do ICU time, and are orthopods capable of running a trauma room if necessary (understanding that it's primarily the trauma/general surgeon's responsibility)?

b

as i understand, in europe it is the orthopaedic surgeons that coordinate the management of major trauma. in addition, it was an orthopaedic surgeon that first described the first ATLS protocols. maybe a residency in GB might be your thang

it's not that i'm dying to be the trauma guy, cuz then i'd be doing trauma. i'm just getting a feel for how much medicine there is in ortho. i can't possibly do anything medicine for more than a 3 month rotation, but at the same time, as a future doctor, i do like medicine a little bit.

just trying to get a feel for whether orthopods do anything remotely medicine. i guess i should have known a long time ago, but it just hit me recently that of all the subspecialties, ortho may well be among the least medicine of the medical fields. not the least, but nearly.

and maybe that will be a great thing, i don't know. but just trying to clarify before i jump.

thanks.
b

Look into metabolic bone dz. It's more than little old ladies with osteoporosis. Several endocrine and renal disorders will fall under this rubric. Can be very interesting stuff.

-Grizzle-

i'd throw in ophtho as another field that has very little medicine. even though most of them do prelim medicine or transitional years (although you can do a surgery prelim), they do very little systemic stuff in their field.

how much medicine you do is up to you

if you want to be the best doctor you can be, it doesn't matter what you go into, you need to read. medical school is meant to be a starting point, not the end of our education.

whether or not you want to subscribe to (and read) NEJM is up to you.

stop trying to pigeonhole specialties into those that pratice medicine and those that do not. it is the doctors who practice within those specialties who can be judged, not the specialty as a whole.

and remember, when you make assumptions, you make and ass out of u and mptions.

peace and humptiness forever

I don't think you will find many private orthopedic docs doing much medicine work other than treating osteoarthritis/tendinitis/bursitis with anti-inflammatories and maybe treating a case of gout now and then and of course the occasional infection. Most of the complex medical management of inflammatory conditions like RA, CTDs, etc... is traditionally managed by rheumatologists or internists. We just don't have the training in those areas especially with the complex drugs that they are using today. Some docs may dabble in metabolic bone disorders, especially if they have their own bone density machine, but they are few and far between.

Just to second this with an anectdote, at my med school we only worked with private pods in a non-academic hospital. No residents of any sort. Almost all of the medicine work in the outpatient and hospital setting was done by the midlevels, not the pods. When the PAs weren't comfortable, standard procedure was a medicine consult without talking to the pods first. The medicine guys of course generally benefited from this...usually simple consults for them...cha-ching.

A note (only) to those that want to maintain some medicine skills... At least at the hospital referred to above, if you were a pod wanting to hone your medical skills, generally the internists were very open to taking time to work with any of the docs who consulted them...to provide ~refresher training/insight etc. I'm sure there are other hospitals out there with similarly good medicine guys willing to help out in this manner. I only mention this as I'm interested in relief work where some of the skills are necessary and I'd like to attain/maintain some proficiency in the future.

So, going back to my original question ... just how easy is it to shape your practice as you wish? People always say (with just about any field in medicine), "you can shape your practice however you like!" But I'm curious how true this is.

For example, the things that I really enjoy right now are hand (probably will want to do a fellowship) & trauma. In addition, I'd like some bread & butter general/sports stuff. I would also like to do some joints ... but that seems to be going to the specialists these days.

Can you actually find that kind of variety in a metropolitan setting? Essentially, I would want to be a specialist in something -- e.g., hand or joint. But I would only want that to take up 50-60% of my practice. I would want to keep up some trauma work, but not so much that calls take over my life -- so maybe 25%. The rest would be a general mix.

Any thoughts?
Thanks.

b

blue...

Your first question: if you enjoy medical management of patients, orthopedics is not the field for you. We routinely consult medicine to manage diabetes, pneumonia, SOB, you name it. Outside of pain meds, NSAIDs and antibiotics, orthopods rarely prescribe any other class of medication. As far as trauma, we deal exclusively with musculoskeletal trauma. There is always a tauma surgeon (general surgeon) in charge of polytraumas who manage the patient's hemodynamic status and overall care. These surgeons consult various services like ortho, neurosurg, urology, etc. for specific injuries that fall within the realm of these fields. So as an orthopaedic traumatologist, your role is strictly as a consultant. You do a year of general surgery, but you soon forget much of it after a couple of years as an ortho resident. There is so much to learn in ortho that you simply don't have time to keep up with problems that a gen surg or internist deals with.

Your 2nd question: it is true that you can shape your practice any way you want...put a "will see puss" sign on your door and you'll have the busiest practice in town. In a metropolitan area, there is competition and you may have to see problems that are 'undesirable' to make a living or build your practice. Once you're established, which can take anywhere from 1-5 years depending on you and the area you live in, you can be more selective. You can be a generalist, do 50% hand, 50% general...or 20% hand, 20% foot, 60% general...you get the idea. You can do a hand fellowship and still do 50% general ortho. Or you can do a hand fellowship and do strictly hand. So bottom line is that you can shape your practice anyway you want, but initially when you start out, you cannot be super-selective because you're the new guy and may have to see patients you wouldn't want to.